Author reply to technical comment

Reply to comment by Poppe C on: Novosel D. Setting as informed consent in psychotherapy. Swiss Med Wkly.2019;149:w20028

Publication Date: 10.11.2019
Swiss Med Wkly. 2019;149:w20146

Nikola Biller-Andorno, Manuel Trachsel

Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland

No exceptionalism for informed consent in psychotherapy

We welcome the debate on informed consent in psychotherapy, which has been long overdue [1]. However, a general statement ascertaining that informed consent is an ethical and legal requirement in all fields of modern medicine including psychotherapy is not enough; practitioners and researchers need to probe how this requirement can best be implemented in clinical practice.

This is why it is important to acknowledge the challenges that specific psychotherapeutic approaches may encounter. One challenge that has been discussed with regard to informed consent in psychotherapy is the exploratory nature of psychodynamic approaches. As a possible response, a “procedural consent” was cited according to which “consequences and constituents of psychotherapy are only disclosed after some psychotherapy has transpired, for example, if they are clinically relevant” [2].

This is not convincing. Vaguely gesturing towards the “intrinsic uncertainty” of psychodynamic psychotherapy cannot serve as a justification for keeping patients out of the loop. It is correct that often informed consent needs to be a process rather than a one-stop shop. This is not only necessary for psychodynamic psychotherapy but also for any other insight- and clarification-oriented approach. However, patients who invest their time and, many times, their money and who carry the risk of any damage that may result from treatments have the right to know a number of facts before committing to an intervention, and not some time along the way. This does not preclude patients changing their mind or requesting additional information once they have embarked on the therapeutic experience.

Among the aspects that need to be addressed are: the nature and goal of the psychotherapeutic intervention; the method that is being applied; the probability of success (at least an estimate and what it is based on); the frequency and duration of sessions; the approximate duration of the treatment; the costs incurred; confidentiality and its limits; risks and unintended effects, as well as the emotional burden caused by the psychotherapy; therapeutic alternatives; and options to interrupt or stop the intervention [3, 4].

If any of these aspects of informed consent are uncertain at the outset of psychotherapy, this needs to be discussed with the patient. Other psychotherapeutic approaches such as cognitive-behavioural therapy, existential-humanistic therapy or systemic therapy, as well as other areas in medicine more broadly, also struggle with considerable degrees of uncertainty, for example regarding outcomes. Yet this does not serve as a justification for an ethical exceptionalism.

When dealing with practical issues of how to best implement the informed consent requirement, it might be of interest to note the recent move away from informing the patient and getting his or her consent towards the concept of shared decision-making [5]. Shared decision-making is considered a stepwise procedure between patient and provider that aims to enable evidence-based patient choice through a process of listening, informing, discussing, deciding, and documenting [6]. This process allows a negotiation of what the patient expects and is willing to invest and what the provider is able and willing to offer. Acknowledging and dealing with uncertainties is a regular part of this process.

Disclosure statement

No financial support and no potential conflict of interest relevant to this article was reported.


Prof. Nikola Biller-Andorno, MD, PhD, Institute of Biomedical Ethics and History of Medicine, University of Zurich, Winterthurstrasse 30, CH-8006 Zurich, biller-andorno[at]


1 Trachsel M, Holtforth MG, Biller-Andorno N, Appelbaum PS. Informed consent for psychotherapy: still not routine. Lancet Psychiatry. 2015;2(9):775–7. doi:. PubMed

2 Poppe C. Informed consent to (psychodynamic) psychotherapy needs disclosure of uncertainty. Swiss Med Wkly. 2019;149:w20145. doi:

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6 Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al.Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7. doi:. PubMed

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